Introduction: Sexual and gender minority youth are at higher risk for nicotine/tobacco use than cisgender and/or heterosexual youth. Little is known about how the use of multiple tobacco/nicotine products differs among youth by sexual orientation and gender identity. This study sought to determine whether the lifetime number of tobacco/nicotine products differs by sexual orientation and gender identity.

Methods: This study is a cross-sectional analysis of nationally representative data on 14 457 students ages 9-19+ who participated in the 2023 National Youth Tobacco Survey. Weighted means, adjusted odds ratios, and adjusted incidence rate ratios were used to assess differences in the number of lifetime tobacco/nicotine products used by students in the following groups: cisgender heterosexual; cisgender sexual minority; gender minority heterosexual; and gender and sexual minority youth.

Results: Adjusting for age, race/ethnicity, and sex, gender minority heterosexual youth used more than twice as many tobacco/nicotine products as their cisgender heterosexual peers, with an adjusted incidence rate ratio (aIRR) of 2.47; 95% confidence interval (CI), 1.10-5.56; p=.030. Gender and sexual minority youth also used twice as many methods as their cisgender heterosexual peers (aIRR, 2.05; 95% CI, 1.40-2.98; p<.001).

Conclusion: Among youth aged 9-19+ years, gender minority youth of any sexual orientation used a higher lifetime number of tobacco/nicotine products than did cisgender heterosexual youth. Prevention, harm reduction, and cessation programs for youth are needed to respond to the upward trend of multiple tobacco product use among youth and the specific needs of gender minority youth.

Objective: Strategies are needed to increase adolescent and young adult (AYA) engagement in nicotine use treatment. We assessed feasibility, acceptability, and clinical impact of text-message outreach connecting AYA to nicotine use treatment across a large health network.

Methods: This quality improvement pilot study included two phases of text-message outreach following primary care visits. All patients aged 13-22 completed an in-visit confidential electronic health questionnaire assessing past 30-day nicotine use. Phase 1: patients selected whether to receive text outreach about quitting resources. Phase 2: all patients reporting nicotine use who provided a phone number on the electronic questionnaire received automatic text outreach. Treatment options included a text-messaging program (This is Quitting) and/or nicotine replacement therapy. Outcome measures included feasibility (phone number provision), acceptability (treatment interest), and clinical impact (treatment connection).

Results: Among 23,411 AYA screened February-June 2024, 919 (3.9%) reported past 30-day nicotine use. For feasibility, 90% and 91% of AYA who reported nicotine use provided a phone number in each phase, respectively. Acceptability was higher in Phase 1 versus Phase 2 (11% vs. 2%), but clinical impact was similar (2% vs. 1%). Overall, 824 patients who reported nicotine use provided a phone number (90%), 59 expressed treatment interest (6%), and 16 connected to treatment (2%).

Conclusions: Text-message outreach was feasible but achieved low acceptability and clinical impact. Barriers included a high rate of messages blocked as spam, limited interventions for AYA with infrequent nicotine use, and barriers to accessing NRT related to cost and confidentiality.

Objectives: To examine the temporal trends of current cannabis use only, tobacco use only, and co-use of these two substances by racial and ethnic adolescent groups.

Methods: Data were drawn from the 1991-2021 Youth Risk Behavior Surveys (YRBS) (n = 234,572) to examine changes in cannabis and tobacco use among American Indian or Alaskan Native (AI/AN), Asian, Black, Hispanic/Latino (H/L), Native Hawaiian or other Pacific Islander only (NH/PI), White, and multi-racial high school students. Multivariable logistic regressions were performed to examine racial and ethnic disparities in current cannabis and tobacco use across four equal interval periods (i.e., 1991-1997, 1999-2005, 2007-2013, 2015-2021).

Results: During 2015-2021, Black (12.6% (95% CI11.3-13.9%)), H/L (9.0% (7.9-10.1%)), and multi-racial (8.8% (7.3-10.3%)) adolescent reported higher prevalences of cannabis-only use than whites (4.9% (4.4-5.5%)), while AI/AN (20.1% (15.1-25.2%)) reported higher prevalence of tobacco and cannabis co-use than whites (13.4% (12.2-14.5%)). The prevalence of cannabis-only use was highest among Black adolescents and increased from 10.8% (9.3-12.2%) in 1991-1997 to 12.6% (11.3-13.9%) in 2015-2021 (linear trend, p = .004), while AI/AN adolescents maintained the highest prevalences of cannabis and tobacco co-use across last three decades (p = .17) with 23.0% (16.6-29.4%) in 1991-1997 to 20.1% (15.1-25.2%) in 2015-2021. As compared to their White counterparts, Black and H/L adolescents consistently exhibited higher prevalences of reporting cannabis-only use, but lower tobacco-only use; AI/AN adolescents had higher cannabis-tobacco co-use and Asian adolescents reported lower cannabis and tobacco use.

Conclusions: These disparities highlight the importance of public health programs addressing diverse substance use behaviors across racial and ethnic groups. There is a need for early prevention and tailored interventions to reduce cannabis-only use among Black adolescents and tobacco-cannabis co-use among American Indian/Alaskan Native adolescents.

Introduction: Understanding which theories have been effectively applied in tobacco control efforts for sexual and gender minority (SGM) individuals will help identify constructs to incorporate into future tobacco control efforts aimed at reducing SGM tobacco disparities. This scoping review summarizes the use of theory in SGM-focused tobacco control efforts.

Methods: We searched four databases using SGM- and tobacco-focused terms in November 2023. Two trained coders independently screened each title and abstract, reviewed the full text, and extracted data about theories used and which tobacco control measures from the World Health Organization Framework Convention on Tobacco Control were included.

Results: The final analytic sample included 86 papers. Of those, 11 (12.9%) discussed price/tax manipulations, 15 (17.7%) discussed secondhand smoke and smoke-free policies, 11 (12.9%) discussed product characteristics (e.g., flavors), 5 (5.9%) discussed product disclosures (e.g., warning labels), 7 (8.1%) discussed packaging, 23 (27.1%) discussed education, communication and public awareness, 15 (17.7%) discussed tobacco advertising and promotion, 49 (57.7%) discussed tobacco prevention/cessation interventions, and 1 discussed Tobacco 21 (1%). Under half (31 articles, 36.0%) explicitly presented theoretical models.

Conclusions: This review found a relative lack of theoretical models applied in tobacco control initiatives for SGM people. Of the 31 studies that did, most used theory to help clarify the etiology and associated factors of tobacco use (e.g., minority stress, increased exposure to marketing) or tailor prevention/cessation interventions focused on SGM individuals. Future studies should be grounded in theory to increase the effectiveness of these activities while preventing potential unintended consequences.

Implication: This scoping review aimed to summarize which theoretical models have been implemented in relation to tobacco control measures among SGM individuals. Most theories were integrated in helping explain disparities or tailor interventions. Large-scale tobacco control initiatives may cause unique harm to SGM samples when critical theories are not integrated into their design and implementation.

Background: Due to the colonization of tobacco plants by European settlers and the subsequent intensive marketing of commercial tobacco products to American Indian and Alaska Native (AI/AN) communities in the United States, commercial cigarette smoking accounts for half of all deaths among AI/AN people. Limited awareness, access to treatment, and the absence of culturally relevant, effective smoking cessation interventions contribute to these high death rates.

Objective: This study aims to culturally adapt iCanQuit, a smartphone smoking cessation app proven efficacious for the general population, for AI/AN people.

Methods: A user-centered and community-based participatory research (CBPR) mixed methods approach was applied to culturally adapt iCanQuit for AI/AN people in collaboration with a community advisory board (CAB) of AI/AN individuals using a 3-step process. Step 1 identified ways to culturally adapt the iCanQuit for AI/AN people through 1-on-1 qualitative interviews with 8 prior iCanQuit AI/AN participants. Step 2 involved developing prototypes of cultural refinements identified in step 1 through regular biweekly meetings of the CAB, research, and app development teams. The prototypes were then evaluated with a separate group of 4 prior iCanQuit AI/AN participants through 1-on-1 qualitative interviews. Step 3 involved beta testing the app through a 6-day diary study followed by 1-on-1 qualitative interviews with a nationally recruited group of 7 AI/AN adults who smoke commercial cigarettes. The development work associated with step 3 was further informed by the CAB and the research and app development teams.

Results: Key findings identified 5 cultural refinements that informed subsequent app development and testing: (1) stories featuring AI/AN adults and elders emphasizing culture, spirituality, family, and community; (2) honoring the Earth as a motivator for cessation; (3) a guide character representative of AI/AN people; (4) clear distinction between ceremonial and commercial tobacco use; and (5) use of earth tones in visual design. In Step 3, all 7 (100%) diary study participants rated the beta version of the app as excellent or good/meets expectations (5/7, 71%, and 2/7, 29%, respectively) and that it felt made for them. They suggested 6 modifications which were incorporated into the final version of the app: (1) include vaping frequently asked questions, (2) feature motivation icons more prominently, (3) increase notification frequency, (4) track today's cigarettes rather than yesterday's, (5) allow users to update how much they spend per pack of cigarettes; and (6) rename the medications tool to reflect the inclusion of AI/AN traditional healing modalities.

Conclusions: A user-centered and CBPR development process yielded IndigeQuit-one of the first known apps developed specifically to help AI/AN adults quit commercial cigarette smoking.

Trial registration: ClinicalTrials.gov NCT06145763; https://clinicaltrials.gov/ct2/show/NCT06145763.

Significance: Understanding how integrated tobacco tax policies influence purchasing decisions across socioeconomic groups is critical to advancing tobacco control in an equitable manner in the context of the rapidly evolving tobacco and nicotine product market. Using an Experimental Tobacco Marketplace (ETM), this study examined the effects of four multitiered tax policies on tobacco purchasing among people who smoke cigarettes. Each policy used a different strategy to attain the goal of reducing cigarette purchasing among three socioeconomic groups. The policies were: tobacco parity, nicotine content, harm reduction and modified risk tobacco products.

Methods: A sample representative of the US population (N=481) was recruited from a national survey panel (Prolific). Using a within-subject/between-subject factorial design, participants completed hypothetical purchasing trials in the ETM with products priced under the four multitiered tax policies. Higher tiers equated to higher taxes.

Results: Higher taxes consistently reduced relative spending, while relative spending on medium-tax and no-tax tier products varied by tax proposal. The nicotine content tax policy led to the largest reduction in high-tax tier spending and the greatest shift toward no-tax products (eg, nicotine replacement). No socioeconomic differences were observed.

Conclusions: These findings indicate that strategic taxation is a robust and adaptable tool for shifting tobacco purchasing. Integrated tobacco tax policies are likely to be effective at reducing consumption of the highest-risk products without a disproportionate socioeconomic impact.

Trial registration number: NCT06795997.

Introduction: Increasingly, U.S. states and localities are passing policies to restrict menthol and other characterizing flavors in tobacco products. Given the disproportionate use of flavored tobacco among historically marginalized groups, such restrictions have the potential to promote health equity. This scoping review aimed to characterize community perceptions of flavor restrictions using an equity lens.

Methods: We conducted a PubMed search for U.S.-based studies that reported on flavor restriction outcomes, disaggregated by race, ethnicity, or lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity.

Results: Across the 22 studies identified, two foci emerged: factors influencing the passage of flavor restrictions (eg, policy support) and the impacts of implementing these restrictions (eg, cessation intentions). Support for flavor restrictions varied by product and population: menthol cigarette restrictions received notably higher support among African American and Hispanic communities, while evidence for e-cigarette flavor restrictions was mixed-some studies reported minimal subgroup differences, whereas others reported higher support among specific racial/ethnic groups. A few studies discussed unintended consequences, such as product substitution or engagement with illicit channels; these studies were also mixed regarding which racial/ethnic groups would be most impacted. Key research gaps included long-term behavioral outcomes and outcomes across LGBTQ identities.

Conclusions: While there are clear racial/ethnic differences for support of menthol cigarette bans, much of the literature on other types of flavor restrictions is mixed. Further research is needed to resolve these discrepancies and expand beyond race and ethnicity when disaggregating subgroups. Such efforts are critical to ensuring flavor restrictions achieve their intended public health benefits and advance health equity.

Introduction: The purpose of this study was to characterize the dose-response relationship between duration of cognitive-behavioral counseling and abstinence in individuals who participated in a randomized controlled trial for smoking cessation.

Methods: This is a secondary analysis of participants enrolled in double-blind randomized controlled trials for smoking cessation consisting of 12 weeks of pharmacotherapy (placebo; N = 142; varenicline; N = 257) combined with counseling. Participants were 41% female, 66% non-Hispanic White, who smoked a median of 20 cigarettes per day. Seven-day point prevalence (7-dayPP) and prolonged abstinence were calculated at the end of treatment and at the 6-month follow-up.

Results: All abstinence outcomes exhibited sigmoidal (s-shaped) relationships with duration of counseling, and the median effective duration was similar (ranging from 130 to 160 min). The sigmoidal curves between placebo and varenicline were significantly different (7-dayPP at end of treatment; EOT: F = 14.68, p < .01) The difference between the maximum efficacy for the medications is 0.34 (p-value < 0.01) for 7-dayPP abstinence at EOT, indicating ~35% higher rates of abstinence at the maximum efficacy of counseling for those in the varenicline group as compared with those in the placebo group.

Conclusions: Participants who received counseling and pharmacotherapy to quit smoking exhibited a duration-dependent response of abstinence to counseling captured by a sigmoidal curve that exhibited variation in the maximum efficacy between placebo and varenicline, suggesting either that counseling for smoking cessation enhanced the effect of varenicline on abstinence, or more likely, that counseling was more effective in achieving abstinence in the presence of varenicline.

Implications: The results suggest that cognitive-behavioral counseling for smoking cessation is more effective in achieving abstinence in the presence of varenicline or less likely, that counseling enhanced the effect of varenicline on abstinence. Optimizing the duration of counseling, particularly when coupled with pharmacotherapy, can offer more tailored and efficient cessation strategies. This finding emphasizes that the integration of behavioral and pharmacological approaches is crucial for maximizing the effectiveness of smoking cessation interventions, consistent with previous evidence and current guidelines.

Introduction: Cigarette smoking is the world's leading preventable cause of death. With no new smoking cessation pharmacotherapy approved since 2006, the 29 million US adults who smoke need new treatment options. Cytisinicline, a partial agonist at α4β2 neuronal nicotinic acetylcholine receptors, is the name of a new dosing regimen of cytisine, a smoking cessation pharmacotherapy that has been sold for decades in Eastern Europe but is currently unavailable in the US. The Food and Drug Administration is evaluating a New Drug Application for cytisinicline.

Areas covered: We summarize the history, chemistry, pharmacodynamics, and pharmacokinetics of cytisine and cytisinicline and explain their different dosing regimens. Two Phase 3 randomized double-blind placebo-controlled trials have demonstrated cytisinicline's efficacy and safety for smoking cessation in US adults. We review the trial results in the context of previous evidence supporting cytisine and other cessation medications.

Expert opinion: Cytisinicline has a strong evidence base to support US licensure as a smoking cessation aid. If approved and its effectiveness in clinical practice confirms its clinical trial efficacy, cytisinicline will likely join varenicline and combination nicotine replacement as a first-line smoking cessation treatment option. It may also aid cessation of electronic-cigarette vaping or other nicotine-mediated dependence disorders.

Background: Although mobile health (mHealth) apps for tobacco cessation augment traditional cessation methods and have contributed to increases in cessation rates, Black adults are underrepresented in mHealth app studies for tobacco cessation. As a result, their mHealth app preferences are not well-known.

Objective: Our goal was to identify features of mHealth apps for cessation that are important to Black adults who use tobacco products.

Methods: We developed an online discrete choice experiment with 12 pairs of hypothetical mHealth apps for tobacco cessation. Inclusion criteria included being 21 years or older, current use of any tobacco product, and identifying as Black or African American. Participants had to be interested in tobacco cessation and have a history of mHealth app use or be willing to use one in the future. From each pair of hypothetical apps within the survey, participants had to choose the app they preferred. Each hypothetical app was made up of 7 features developed from existing mHealth literature and prior qualitative work: graphics, marketing, strategies for quitting, connection with others, personalization, benefits of quitting, and health information. Each feature had up to 4-5 levels (ie, variations of that attribute), and each hypothetical mHealth app was comprised of a random assortment of levels of features. Hierarchical Bayes estimation was used to determine the part-worth utility for each level within each feature for each participant, which was then used to calculate the importance score. Average importance scores across respondents were used to determine overall importance scores for each feature.

Results: We had 901 adult participants. The mean age was 41 (SD 14.02) years, and about a third of participants (377/901, 42%) were female. Two-thirds of participants (549/901, 61%) had used an mHealth app in the past, and the great majority (786/901, 87%) indicated a willingness to use an app for health purposes in the future. The features had the following importance: graphics (16%), marketing (15%), strategies for quitting (15%), connection with others (14%), personalization (13%), benefits of quitting (13%), and health information (13%). Within features, strategies for quitting had the highest and third-highest levels of "making a step-by-step quit plan" and "recommendations to manage relapse or withdrawal," respectively. Marketing had the second-highest level of "Historically Black Colleges and Universities-endorsed app." Graphics had the fourth-highest level of "short video testimonials from people who successfully quit," while connection with others had the fifth-highest level of "quit buddy program for support and accountability."

Conclusions: This study identified features of mHealth apps important to Black adult tobacco users. To enhance the appeal of mHealth apps to such adults, prioritizing inclusion of highly preferred levels in apps may lead to higher use and improved cessation.

Objectives: Some e-cigarette brands have begun offering "boost" modes (aka "pulse" or "turbo"). Our objectives were to (1) Determine the prevalence of boost mode utilisation among adolescents and young adults (AYAs) and (2) Identify the personal and tobacco-use characteristics of AYAs who use boost mode.

Design: Cross-sectional survey from January to July 2025.

Subjects: n=267 AYAs (M age=21.4, SD=2.3, range 14-25) who lived in the US and had used an e-cigarette at least once within the last 30 days. All participants completed a video conference call with study staff before being sent the online survey.

Main outcome measures: AYAs were asked: "Does the e-cigarette or vaping device that you use most often have a "boost" or "pulse" function?". Those who responded "yes" were asked, "How often do you use the "boost" or "pulse" function?".

Results: 55.1% of participants had a device with boost mode. Of these, 54.4% used it "just now and then" or "sometimes", and 27.9% used it "very often" or "always". Participants whose device had (vs did not have) a boost mode were younger, had lower socioeconomic status, used their e-cigarette more frequently (every day or almost every day) and had higher scores on the E-cigarette Dependence Scale. There were no differences by Hooked on Nicotine Checklist score, gender, race and ethnicity or use of other tobacco products.

Conclusion: If, as brands claim, boost modes alter e-cigarette aerosol production, they likely have implications for AYA nicotine addiction and health effects. Longitudinal and laboratory investigations on boost modes are urgently needed.

Objective: Electronic nicotine delivery systems (ENDS) have seen a global surge in their usage. However, their role in smoking initiation, particularly among non-smokers, remains a critical concern. This umbrella review evaluated the risk of tobacco-smoking initiation following ENDS use, focusing on non-smokers, by synthesising evidence using Bayesian meta-analysis.

Study design: Systematic review and Bayesian meta-analysis.

Methods: We searched databases including PubMed, EMBASE and Cochrane Library up to 1 May 2025. We included systematic reviews assessing tobacco-smoking initiation after ENDS use among non-smokers. Quality was evaluated using the AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews - version 2). A Bayesian hierarchical meta-analysis was conducted to estimate pooled ORs with 95% credibility intervals (CrIs), using non-informative priors to model heterogeneity and uncertainty. This study was registered with PROSPERO (CRD42023464207).

Results: From 5055 records, 13 systematic reviews were included. Of them, five were rated as 'high quality', one as 'moderate', four as 'low' and 'three' as critically low, as per AMSTAR-2 quality assessment. The meta-analysis revealed a pooled median OR of 3.1 (95% CrI 2.56 to 3.72) for smoking initiation among non-smoking ENDS users, with moderate heterogeneity (τ mean: 1.23). Among adolescents, the OR was 2.7 (95% CrI 2.27 to 3.21), with moderate heterogeneity (τ mean: 0.63). The risk of relapse in former tobacco smokers who used ENDS was doubled (RR: 2.03, 95% CI 1.39 to 2.96). Individuals who had never smoked but engaged with ENDS had more than twice the odds of developing an intention to smoke, with an OR of 2.21 (95% CI 1.86 to 2.61). The overall certainty of the evidence was rated very low due to the risk of bias in the studies and evidence of publication bias across the studies.

Conclusions: ENDS use is significantly associated with increased risk of tobacco smoking initiation among non-smokers, particularly adolescents, supporting the gateway hypothesis. These findings indicate the need for stringent regulatory and public health strategies to protect people from nicotine addiction.

Purpose: California's longstanding, comprehensive tobacco control program includes the school-based Tobacco-Use Prevention Education (TUPE) program. Following passage of Proposition 56 in 2016, TUPE was expanded. This study investigated whether exposure to TUPE programming after Proposition 56 was associated with decreased youth tobacco use.

Methods: Data from the 2019-2020 California Student Tobacco Survey, a state-representative survey of students in grades 8, 10, and 12, were used. The survey was conducted in 358 schools. A total of 160,106 students (49,244 from TUPE-funded schools and 110,862 from non-TUPE-funded schools) were included in this study. The association of TUPE programming with student tobacco use was examined using logistic regression, controlling for the effects of personal and school variables.

Results: Students from TUPE and non-TUPE schools had similar rates of exposure to tobacco-related advertising, whether promoting vaping (16.4% vs. 16.8%, respectively), discouraging vaping (36.3% vs. 38.7%), promoting smoking (11.4% vs. 11.4%), or discouraging smoking (27.6% vs. 29.4%; all p's > 0.05). However, TUPE students were more likely to receive school-based education against tobacco use (71.0% vs. 63.8%; p < 0.001) and to participate in antitobacco activities (15.2% vs. 10.6%; p < 0.001). After controlling for the effects of personal and school variables, TUPE students were less likely to use tobacco (6.5%) than non-TUPE students (8.1%; p = 0.012).

Discussion: TUPE students were exposed to more school-based educational messaging and participated in more tobacco-related prevention activities. The greater focus on tobacco in TUPE-funded schools was associated with lower rates of tobacco use among their students.

Introduction: Although electronic cigarettes (e-cigarettes) have demonstrated efficacy for quitting combustible cigarette smoking, they also convey inherent risks. How the public views e-cigarettes and their potential harm may influence how e-cigarettes are used. We therefore evaluated perceptions of e-cigarettes over a recent 10-year period.

Methods: Longitudinal data from a multiyear cross-sectional nationally representative survey, Health Information National Trends Survey, were analyzed to assess changes in perceptions of e-cigarettes' harm relative to cigarettes and factors affecting perceptions among US adults from 2012 to 2022. We used interrupted time series regression analysis to determine possible associations with key public health events.

Results: A total of 20 771 survey respondents were included in the analysis. From 2012 to 2022, the proportion perceiving e-cigarettes as more harmful than combustible cigarettes increased from 2.8% (95% CI, 1.8%-3.9%) to 30.4% (95% CI, 28.2%-32.7%). Likewise, perceptions of e-cigarettes as less harmful decreased from 50.7% (95% CI, 47.6%-53.9%) to 16.7% (95% CI, 14.9%-18.6%). Perceptions changed significantly following the national rollout of anti-vaping campaigns (p < .001) and the e-cigarette or vaping product use-associated lung injury outbreak (p < .001).

Conclusions: Public perceptions of e-cigarettes have shifted markedly over the past decade, with increasing proportions of US adults viewing e-cigarettes as more harmful than combustible cigarettes. These changes appear closely linked to major public health events and campaigns. Understanding how such events influence perceptions is essential for guiding risk communication, public health policy, and future tobacco control strategies.

Implications: How the public views electronic cigarettes (e-cigarettes) and their potential harm may influence how e-cigarettes are used. Although e-cigarettes convey risks, they have also demonstrated efficacy for quitting combustible cigarette smoking. We found that perceptions of e-cigarettes have shifted markedly over the past decade, with increasing proportions of US adults viewing e-cigarettes as more harmful than combustible cigarettes. How such perceptions influence smoking behavior represents an important consideration for risk communication, public health policy, and tobacco control strategies. Clear, evidenced-based messaging may reduce uptake of e-cigarette use, support harm-reduction efforts for current smokers, and promote trust in public health institutions.

Introduction: E-cigarettes are the most frequently used tobacco product among adolescents and young adults. Over 40% of adolescents who used e-cigarettes tried quitting in 2023, but few programs support them, particularly on social media.

Objective: Test the efficacy of e-cigarette cessation support groups on Instagram in a randomized controlled trial.

Study design: 500 participants were randomized to intervention or active control with baseline, 5 week (end of program), 3 and 6 month follow up surveys in 2022-2024.

Setting: Healthy volunteers in California were recruited via social media advertisements.

Participants: Participants reported age 13-21 years, English literacy, using social media at least 4 days per week, using e-cigarettes at least weekly, access to device with photo capability, considering quitting within 6 months.

Interventions: Instagram direct message support groups for 5 weeks provided motivational interviewing, social support, skill building, and group quit attempts. Controls were referred to state quitline resources including telephone, online, texting or mobile app.

Main outcome: 7-day point prevalence abstinence from e-cigarette use.

Results: Data was analyzed in 2024-2025. Mean age was 18.9 years, 39.8% female, 51.2% male; 41.1% non-Hispanic white, 17.2% Hispanic, and 27.4% multiracial; 35.1% sexual minority. 70.4% used e-cigarettes daily, and 78.2% within 30 minutes of waking. Retention rates were 43.6% at 5 weeks, 23.0% at 3 months and 28.0% at 6 months. Generalized linear mixed models (GLMM) in a time-averaged difference examined 7-day point prevalence abstinence accounting for repeated measures and clustering effects. Intention to treat analysis counting missing as vaping found greater abstinence in the intervention group (18.2% vs 11.8%) (OR = 2.15, 95% CI = 1.1, 4.2, p=0.025). Complete case analysis also found greater abstinence over 6 months for intervention (53.9%) compared to control (40.4%) (OR = 2.07, 95%CI = 1.21, 3.52, p=0.008). There were no differences in vaping reduction, attitudes, or use of evidence-based methods. Intervention participants reported higher social support with no difference in overall program evaluation.

Conclusions: Social media support groups were acceptable to diverse young people and improved abstinence rates on average over 6 months compared to quitline referral.

Trial registration: Clinicaltrials.gov (protocol # NCT04707911).

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the benefits and harms of using reduced-nicotine cigarettes, compared with standard cigarettes, in people who smoke. To evaluate the benefits and harms of smoking cessation or reduction interventions used as an adjunct to reduced-nicotine cigarettes in people who smoke, compared with the same interventions delivered without reduced-nicotine cigarettes.

Background: A growing body of research supports the efficacy of text messaging programs to help tobacco users quit, but texting as a strategy for recruiting tobacco users into other evidence-based cessation services, such as quitline coaching, is less well understood. Texting to offer treatment could increase use of cessation resources, an important consideration for health systems trying to improve their quality metric performance on tobacco assessment and counseling.

Objective: The aim of this study is to compare the effects of text messages offering free quitline coaching or free nicotine patches on engagement with quitline services by patients identified in electronic health records as unassisted tobacco users.

Methods: Participants (N=4171) were adult patients of Los Angeles County Department of Health Services who had had a clinical visit in the past 12 months, were willing to receive text messages, and were identified as unassisted tobacco users (ie, those with no documented advice or assistance to quit in the past 24 months). They included 3139 English speakers and 1032 Spanish speakers. Participants were stratified by language, then randomly assigned to one of two groups. Group 1 received a text offering free quitline coaching. Group 2 received a text offering free nicotine patches. The texts were sent in April and May 2022. Outcome measures were the proportions calling the quitline and receiving evidence-based cessation treatments. Data were analyzed in 2025.

Results: Overall, 1.5% (61/4171) of participants called the quitline, including 1.3% (28/2086) in Group 1 and 1.6% (33/2085) in Group 2, and 0.5% (21/4171) received treatment, including 0.4% (8/2086) in Group 1 and 0.6% (13/2085) in Group 2. There was no significant difference either in calls (P=.52) or receiving treatment (P=.29). However, Spanish speakers were significantly more likely to call than English speakers, 2.3% (24/1032) vs 1.2% (37/3139), respectively (P=.008), and engaged in treatment at approximately twice the rate of English speakers, 0.9% (9/1032) vs 0.4% (12/3139), although the latter difference was nonsignificant (P=.07).

Conclusions: A single text was effective in connecting unassisted tobacco users with evidence-based quitline services for both English and Spanish speakers, but especially the latter. A population health approach of reaching out to tobacco-using patients outside clinical visits can meaningfully supplement provider referral. Research is needed on ways to increase the population health impact of this strategy.

From 2010 to 2023, the Smoking Cessation Leadership Center partnered with the Substance Abuse and Mental Health Services Administration to launch the State Leadership Academies (hereinafter, Leadership Academies) to address tobacco use in populations with behavioral health conditions in the United States. The Leadership Academies were a facilitated convening of leaders in tobacco control, behavioral health, and public health who were tasked with creating action plans to reduce the high rates of tobacco use in populations with behavioral health conditions in their states. State partners convened for a 2-day summit between 2010 and 2023, created an action plan, and, in the subsequent 3 to 5 years, implemented and evaluated the action plan in the areas of data, systems, education, or policy. Using a multimethods evaluation approach, we describe short-term outcomes (collaborations), intermediate outcomes (examples of integration of tobacco treatment and policy), and long-term outcomes (decline in tobacco use prevalence) of the Leadership Academies, focusing on 4 state case studies. The case studies highlighted unique partnerships, impactful strategies, the harnessing of state-level infrastructure, and the importance of political will to achieve state-level reductions in tobacco use in populations with behavioral health conditions. The 4 states showed a mean decline of 5.2% in smoking prevalence among people with frequent poor mental health and 6.2% among people with heavy drinking during their Leadership Academy tenure. The case demonstrated the importance of cross-sector collaboration, leadership buy-in, and the creation of sustainable funding structures to support the scaling up of promising projects. Leadership Academies were an effective engagement model to reduce the prevalence of tobacco use in populations with behavioral health conditions.

Importance: Most individuals attempting smoking cessation relapse, even with evidence-based treatment. Mobile interventions offer a potential but largely untested strategy to sustain cessation.

Objective: To test the effectiveness of mobile chat messaging for relapse prevention among individuals who recently quit smoking.

Design, setting, and participants: This randomized clinical trial was conducted from March 14, 2023, to August 15, 2024, at 2 clinic-based smoking cessation services in Hong Kong. Participants were adults who smoked daily and had abstained for 3 to 30 days; they were randomly assigned to an intervention group or a control group.

Interventions: All participants received usual smoking cessation treatment from the services. The intervention group additionally received 3 months of mobile relapse prevention intervention, including chat-based support delivered by a live counselor and access to a supportive chatbot via a messaging app. The control group received 8 text messages on generic smoking cessation advice over 3 months as a contact control.

Main outcomes and measures: The primary outcome was biochemically validated tobacco abstinence at 6 months after randomization, defined by an exhaled carbon monoxide level of less than 5 ppm or a negative salivary cotinine test result. Secondary outcomes at 6 months included self-reported prolonged abstinence, 7-day point prevalence abstinence, and relapse (7 consecutive days of smoking) rate. Intention-to-treat analyses were conducted, assuming participants with missing outcomes relapsed.

Results: Of 590 participants, 465 (78.8%) were male, and the mean (SD) age was 47.1 (11.2) years; 294 were randomized to the intervention group and 296 were randomized to the control group. The retention rate at 6-month follow-up was 98.0% (n = 578). Biochemically validated abstinence at 6 months was significantly higher in the intervention group than in the control group (45.9% [135 of 294] vs 35.5% [105 of 296]; relative risk [RR], 1.29; 95% CI, 1.06-1.58; P = .01). The intervention group also reported significantly higher prolonged abstinence (57.5% [169 of 294] vs 47.6% [141 of 296]; RR, 1.21; 95% CI, 1.03-1.41; P = .02), higher 7-day point prevalence abstinence (65.6% [193 of 294] vs 54.7% [162 of 296]; RR, 1.20; 95% CI, 1.05-1.37; P = .007), and lower relapse rate (33.0% [97 of 294] vs 44.9% [133 of 296]; RR, 0.73; 95% CI, 0.60-0.90; P = .003) at 6 months.

Conclusions and relevance: This randomized clinical trial found that mobile chat messaging for smoking relapse prevention increased validated abstinence by approximately 30%, offering a scalable approach to sustain abstinence among individuals who recently quit smoking.

Trial registration: ClinicalTrials.gov Identifier: NCT05370352.

Background: Flavours play a key role in e-cigarette initiation and continued use among US youth. In 2021, e-cigarette manufacturers introduced ostensibly unflavoured products using a 'clear' descriptor. Using a mixed-methods approach, this study describes trends in retail sales and terminology used in online marketing or advertising of clear-flavoured e-cigarettes.

Methods: We used NielsenIQ retail scanner data from October 2021 to August 2024 to estimate market share and changes in market share of clear-flavoured e-cigarettes. In addition, using the keywords "vape," "e-cigarette," "clear," and "flavor," six online searches were conducted in January and June 2024 to determine whether flavour or sensory terminology was used to describe clear-flavoured e-cigarettes. Trained coders recorded terminology in the product descriptions.

Results: NielsenIQ data showed the market share of clear-flavoured e-cigarettes increased from US$34K in October 2021 to over US$1M by August 2024, representing 0.03% and 0.59% of the disposable e-cigarette market, respectively. Our analysis of product descriptions found that cooling-related terms like 'menthol' appeared in 25 of the 47 online listings (53.2%). An additional 10 (21.3%) descriptions included non-specific flavour and taste language, such as 'classic taste' and 'smooth flavour', suggesting the presence of flavourings without clearly indicating the specific taste profile.

Conclusion: The presence of flavour terminology in clear-flavoured e-cigarette product descriptions suggests that purportedly unflavoured products, such as clear-flavoured e-cigarettes, are marketed with language that implies flavoured characteristics. E-cigarettes classified as 'clear' flavour may bypass state and local flavour restrictions, advertising flavour experiences that appeal to youth.

Introduction: Couple-based smoking cessation interventions can be more effective than individual ones in initiating and maintaining cessation behaviors, but they often require costly in-person visits. More affordable and accessible options are needed. The aim of this study was to develop a couple-based, web-app, WeQuit, for smoking couples and to pilot-test its feasibility, acceptability, and preliminary effects.

Methods: Using Family Systems theory, WeQuit was developed focusing on three relational constructs: communal coping, smoking-system fit, and ironic processes. Feasibility was evaluated by completion rates and time spent on the app. Acceptability was determined by using standardized measures of perceived usability and satisfaction with WeQuit. Preliminary effects were determined by changes in smoking-related and relational couple dynamic variables.

Results: Forty couples were invited and completed WeQuit. Nearly half of the primary smoking participants were female (n = 20, 50.0%) and Black (n = 18, 45.0%). About 77.5% (n = 31/40) and 45.0% (n = 18/ 40) completed more than half and 100% of the program, respectively. WeQuit was perceived as "very useful" (80.0 %) and "very easy to use (87.0 %). Respondents felt 'very confident developing quit plans' (80.0 %) and 'very satisfied" (87.0 %). WeQuit significantly improved positive partner support (p<.001). Participants who quit showed significant improvements in positive partner support (p<.001) and dyadic efficacy (p=.006).

Conclusions: This study reveals that the theory-guided couple-based web-app, WeQuit, holds promise for promoting smoking cessation among smoking couples. Future research will involve a large pilot trial to evaluate the effectiveness of WeQuit on smoking cessation outcomes.

Introduction: Smoking rates among sexual and gender minority (SGM) adults are generally higher than those in the general population. Tailoring anti-smoking messages for SGM young adults is a promising strategy to reduce health inequalities, but ignoring the difference between gender groups within the SGM community is problematic.

Methods: We conducted two experiments to examine whether gender expression affected the perceived targetedness (PT) among SGM young adults aged 18 to 30. In the first study, participants were randomly assigned to view 8 out of 80 images using various gender expressions. In the second study, participants were randomly assigned to one of four conditions (transgender/nonbinary expressions vs. feminine expressions vs. masculine expressions vs. multiple gender expressions) and viewed 6 anti-smoking campaign messages in each condition.

Results: Both studies found that compared to messages with other gender expressions, gender-expansive individuals reported higher PT when viewing messages with transgender/nonbinary expressions. Cisgender sexual minority women reported higher PT when viewing messages with feminine expressions. Cisgender sexual minority men reported higher PT when viewing messages with masculine expressions. There was no significant difference in PT between multiple gender expressions and gender expressions matching individuals' gender identity.

Conclusions: Culturally tailored anti-smoking messages using gender expressions matched to gender identity or messages using multiple gender expressions were more effective in achieving PT than messages using unmatched gender expressions.

Implications: Gender is critical to tailoring anti-smoking campaign messages for SGM young adults. We should not view the SGM community as a monolith in smoking interventions and need to tailor messages to different gender groups within the community. Future research should investigate how sexual expressions affect PT and how gender expressions influence persuasion outcomes beyond PT. Additionally, intersectional analyses of multiple social identities may provide deeper insights into the effects of SGM-tailored anti-smoking messages.

Introduction: E-cigarettes ('vapes') are less harmful than cigarettes and effective for smoking cessation. However, public perceptions of their relative harms have worsened over the past decade. In January 2024, the UK government announced a forthcoming ban on disposable e-cigarettes, which received extended media coverage. Concerns were raised that this could exacerbate negative harm perceptions.

Methods: We conducted a repeat cross-sectional study using monthly data from the Smoking Toolkit Study (January 2022-June 2025, the month the ban was implemented). Segmented regression models assessed changes in relative harm perceptions of e-cigarettes vs. cigarettes before and after the January 2024 announcement. Participants were 16,489 people (≥16y) in Great Britain who smoked.

Results: Trends in harm perceptions changed following the announcement of the ban on disposable e-cigarettes. Between January 2022 and January 2024, the proportion who believed e-cigarettes were less harmful declined (RR=0.804 [95%CI=0.764-0.846]), while those believing e-cigarettes were more (RR=1.300 [1.226-1.379]) or equally harmful (RR=1.078 [1.033-1.124]) increased, and the proportion unsure decreased (RR=0.859 [0.805-0.917]). Following the policy announcement, the decline in less harmful perceptions and increase in more harmful perceptions both decelerated significantly (post-announcement trends: RR=0.922 [0.806-1.055]; RR=1.073 [0.939-1.227]). By June 2025, 18.7% [17.1-20.5%] believed e-cigarettes were less harmful, 31.3% [29.1-33.7%] more harmful, 37.5% [35.5-39.6%] equally harmful, and 12.5% [10.9-14.3%] were unsure.

Conclusions: Concerns that the UK government's 2024 vaping policy announcement would exacerbate worsening trends in negative harm perceptions of e-cigarettes among people who smoke appeared unfounded: the rate of deterioration in harm perceptions actually slowed significantly to June 2025. However, harm perceptions still declined, albeit more slowly, and a large proportion of people who smoke continue to hold misperceptions about the relative harms of e-cigarettes.

Implications: Misperceptions about the relative harms of e-cigarettes remain common among people who smoke in Great Britain. The slowing of negative trends following the disposable ban announcement suggests the policy announcement did not worsen deteriorating harm perceptions as feared. Nonetheless, with only one in five adults who smoke recognising that e-cigarettes are less harmful than cigarettes, clear communication from public health bodies, government, and via the media is needed to address ongoing misconceptions. Future research should assess whether implementation of the ban in June 2025 has different effects on harm perceptions.

Background: Although mobile health (mHealth) apps for tobacco cessation augment traditional cessation methods and have contributed to increases in cessation rates, Black adults are under-represented in mHealth app studies for tobacco cessation. As a result, their mHealth app preferences are not well known.

Objective: Our goal was to identify features of mHealth apps for cessation that are important to Black adults who use tobacco products.

Methods: We developed an online discrete choice experiment with 12 pairs of hypothetical mHealth apps for tobacco cessation. Participants included: age > 21 years, current use of any tobacco product, and identifying as Black or African American. Participants had to be interested in tobacco cessation and have a history of mHealth app usage or be willing to use one in the future. From each pair of hypothetical apps within the survey, participants had to choose the app they preferred. Each hypothetical app was made up of seven features developed from existing mHealth literature and prior qualitative work: graphics, marketing, strategies for quitting, connection with others, personalization, benefits of quitting, and health information. Each feature had up to 4 -5 levels (i.e., variations of that attribute), and each hypothetical mHealth app was comprised of a random assortment of levels of features. Hierarchical Bayes estimation was used to determine the part-worth utility for each level within each feature for each participant, which was then used to calculate the importance score. Average.

Results: We had 901 adults participants. The mean age was 41 (SD 14.02), and 377 (42%) were female. Two thirds of participants (549/901, 61%) had used an mHealth app in the past, and the great majority (786/901, 87%) indicated a willingness to use an app for health purposes in the future. The features had the following importance: graphics (16.5%); marketing (15.1%); strategies for quitting (15.0%); connection with others (14.3%); personalization (13.4%); benefits of quitting (13.1%) and health information (12.6%). Within features, strategies for quitting had the highest and third-highest levels of "making a step-by-step quit plan" and "recommendations to manage relapse or withdrawal" respectively. Marketing had the second highest level of "HBCU-endorsed app." Graphics had the fourth highest level of " short video testimonials from people who successfully quit" while connection with others had the fifth highest level of "quit buddy program for support and accountability."

Conclusions: This study identified features of mHealth apps important to Black adult tobacco users. To enhance the appeal of mHealth apps to such adults, prioritizing inclusion of highly preferred levels in apps may lead to higher usage and improved cessation.

Introduction: Healthcare systems could reduce disparities in the toll of tobacco use by advising all patients who use tobacco to quit. This study examined U.S. adult population-based estimates of past-year tobacco use and of healthcare provider advice to quit tobacco and disparities in these rates across sociodemographic and substance use characteristics.

Methods: Cross-sectional data from the 2015-2019 National Survey on Drug Use and Health were used to estimate the rates of tobacco use and tobacco cessation advice as a function of patient sociodemographic characteristics and other substance use.

Results: A total of 28% of U.S. adult healthcare patients reported past-year tobacco use. Only 52% of them recalled receiving tobacco cessation advice from healthcare providers. Tobacco use was elevated among people with co-occurring substance use or disorders; men; non-Hispanic White people; those identifying as lesbian, gay, or bisexual; those with incomes below $30,000; those with no college degree; those in rural areas; and those with non-Medicare or no insurance. Rates of receiving quitting advice were lower among people who use alcohol or cannabis; those with cannabis use disorder; men; minoritized racial/ethnic groups; those with incomes below $30,000; and those in urban areas. Conversely, people with no college degree and public insurance and those with alcohol or illicit drug use disorder reported higher advising rates.

Conclusions: Some groups with high tobacco use prevalence receive quitting advice at low rates. Healthcare provider advice to quit tobacco may not reach all patients who use tobacco, particularly those with co-occurring alcohol or cannabis use or cannabis use disorder.